Pediatric Coding Alert

Question: How do the new on-call codes apply? Insurers will likely not pay for the time we are on-call but not seeing patients (even though that sounds like what the code describes "on-call services" in or out of the hospital). How can we use this code when no patient is seen? Can you help me clarify when I should use this code? Louisiana Subscriber Answer: Unfortunately, the 2003 Medicare National Physician Fee Schedule does not grant any relative value units (RVUs) for either of the new on-call codes, 99026 (Hospital mandated on-call service; in-hospital, each hour) and 99027 ( out-of-hospital, each hour). In the schedule's preamble, CMS notes that the AMA's relative value update committee (RUC) made no recommendations for these codes.

Most important, Medicare does not cover standby and on-call services and will not pay for them when billed using these codes, according to the preamble. Therefore, 99026 and 99027 may fall into the typical noncoverage scenario similar to that for telephone calls codes (99371-99373) exist that describe the service, but many insurers will not pay for them. Although you cannot bill on-call services to Medicare carriers, you should try billing third-party payers. The special services, procedures and reports subsection (99000-99091) allows the reporting physician to identify the completion of special reports and services in addition to the basic services rendered, according to the subsection's introductory notes. You may bill 99026-99027 with other codes in this section, such as 99050 (Services requested after hours in addition to basic service). The on-call codes do not replace physician standby service (99360). If another doctor requests that you provide prolonged physician attendance for a patient who may need attention and the service does not result in a procedure (the service does not involve any face-to-face patient contact), you should report 99360 (Physician standby service, requiring prolonged physician attendance, each 30 minutes [e.g., operative standby, standby for frozen section, for cesarean/high-risk delivery, for monitoring EEG]). Obviously, you would bill 99360 to the patient for whom the doctor was on-call. Many coders, however, have requested information regarding whom they would bill for 99026-99027. In this regard, coders are interpreting hospital-mandated on-call service in the general sense of physician on-call duties. This interpretation, however, creates a billing dilemma in that no patient exists to bill the service. CPT Changes 2003 and the Coders'Desk Reference offer no further interpretations concerning how to apply the on-call codes. Therefore, until CPT Assistant further clarifies the codes, consider 99026-99027 the equivalent of 99360 when the hospital, rather than a physician, requires you to remain on-call for a specific patient. In this way, you have a specific person you can bill.

If you provide physician-requested attendance at delivery for a [...]